I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Dr. Boutwell all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

______________________________________

Please print name of Patient, Parent, Guardian or Personal Representative

In Case of Emergency, Contact (Specify someone who does not live in your household)

Last Name of Emergency Contact

First Name of Emergency Contact

Relationship to Emergency Contact

Emergency Contact Home Phone

Emergency Contact Work Phone

Dental History

Reason for Today's Visit

Former Dentist

City of Former Dentist

State of Former Dentist

Date of Last Dental Visit

Date of Last Dental X-rays

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Bad breath

Yes

No

Bleeding Gums

Yes

No

Blisters on Lip or Mouth

Yes

No

Burning Sensation on Tongue

Yes

No

Chew on One Side of Mouth

Yes

No

Cigarette, Pipe, Cigar Smoker

Yes

No

Clicking or Popping Jaw

Yes

No

Dry Mouth

Yes

No

Fingernail Biting

Yes

No

Food Collection Between Teeth

Yes

No

Foreign Objects

Yes

No

Grinding Teeth

Yes

No

Gums Swollen or Tender

Yes

No

Jaw Pain or Tiredness

Yes

No

Lip or Cheek Biting

Yes

No

Loose Teeth or Broken Filling

Yes

No

Mouth Breathing

Yes

No

Mouth Pain, Brushing

Yes

No

Orthodontic Treatment

Yes

No

Pain around Ear

Yes

No

Periodontal Treatment

Yes

No

Sensitivity to Cold

Yes

No

Sensitivity to Heat

Yes

No

Sensitivity to Sweets

Yes

No

Sensitivity to Biting

Yes

No

Sores or Growths in Mouth

Yes

No

How Often do You Floss

How Often do You Brush

Health History

Physician's Name

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine).Pondimin (fenfluramine) and Redux (dexfenfluramine):

Yes

No

Place a mark on "yes" or "no" to indicate if you have had any of the following:

AIDS/HIV

Yes

No

Anemia

Yes

No

Arthritis, Rheumatism

Yes

No

Artificial Heart Valves

Yes

No

Artifcial Joints

Yes

No

Asthma

Yes

No

Back Problems

Yes

No

Bleeding abnormall, with extractions or surgery

Yes

No

Blood Disease

Yes

No

Cancer

Yes

No

Chemical Dependency

Yes

No

Chemotherapy

Yes

No

Circulatory Problems

Yes

No

Congenital Heart Lesions

Yes

No

Cortisone Treatments

Yes

No

Cough, persistant or bloody

Yes

No

Diabetes

Yes

No

Emphysema

Yes

No

Fainting or Dizziness

Yes

No

Glaucoma

Yes

No

Headaches

Yes

No

Heart Murmur

Yes

No

Heart Problems

Yes

No

Hepatitis Type _____

Yes

No

Herpes

Yes

No

High Blood Pressure

Yes

No

Jaundice

Yes

No

Jaw Pain

Yes

No

Kidney Disease

Yes

No

Liver Disease

Yes

No

Low Blood Pressure

Yes

No

Mitral Valve Prolapse

Yes

No

Nervous Problems

Yes

No

Pacemaker

Yes

No

Psychiatric Care

Yes

No

Radiation Treatment

Yes

No

Respiratory Disease

Yes

No

Rheumatic Fever

Yes

No

Scarlet Fever

Yes

No

Shortness of Breath

Yes

No

Sinus Trouble

Yes

No

Skin Rash

Yes

No

Special Diet

Yes

No

Stroke

Yes

No

Swollen Feet or Ankles

Yes

No

Swollen Neck Glands

Yes

No

Thyroid Problems

Yes

No

Tonsillitis

Yes

No

Tuberculosis

Yes

No

Tumor or growth on head or neck

Yes

No

Ulcer

Yes

No

Venereal Disease

Yes

No

Weight Loss, Unexplained

Yes

No

Do you wear contact lenses

Yes

No

Women

Are you pregnant

Yes

No

If so, what is your due date

Are you nursing

Yes

No

Are you taking birth control pills

Yes

No

Medications

List any medications you are currently taking and their corresponding diagnosis

Pharmacy Name

Pharmacy Phone

Allergies Please indicate yes or no to any allergies you may have

Aspirin

Yes

No

Barbiturates (Sleeping Pills)

Yes

No

Codeine

Yes

No

Iodine

Yes

No

Latex

Yes

No

Local Anesthetic

Yes

No

Penicillin

Yes

No

Sulfa

Yes

No

Other

Yes

No

If other, please specify

Please fill out the above information, print, and bring to your first appointment. Once you complete this form, please open and print each of the following forms, fill them out (they are all short!), and bring them with you.